Living donor liver transplantation versus donation after circulatory death in the era of normothermic machine perfusion: Insights from a national cohort.

Abstract

The substantial increase in the use of donation after circulatory death livers enabled by normothermic machine perfusion, along with associated improvements in post-transplant outcomes, has raised important questions regarding the contemporary role of living donor liver transplantation. Using Scientific Registry of Transplant Recipients data from January 2021 to August 2024, we compared real-world outcomes of living donor liver transplantation versus donation after circulatory death liver transplantation with and without normothermic machine perfusion and whether these outcomes differed across recipient-, donor-, and center-level subgroups. Death-censored graft and overall patient survival were evaluated using Kaplan-Meier methods and multivariable Cox proportional hazards models adjusted for clinically relevant covariates. Among 6,105 adult recipients, 42.9% underwent donation after circulatory death without normothermic machine perfusion, 28.4% donation after circulatory death with normothermic machine perfusion, and 28.7% living donor liver transplantation. Over time, donation after circulatory death normothermic machine perfusion use expanded broadly across states with increasing adoption at multiple centers, whereas living donor liver transplantation activity remained concentrated in a limited number of high-volume regions and showed minimal growth nationally. Compared with donation after circulatory death transplantation with normothermic machine perfusion, donation after circulatory death transplantation without normothermic machine perfusion was associated with a higher adjusted hazard of graft failure (adjusted hazard ratio, 1.88; 95% confidence interval, 1.25-2.84; P = .0025), whereas living donor liver transplantation was not associated with a statistically significant difference in graft failure (adjusted hazard ratio, 0.82; 95% confidence interval, 0.48-1.41; P = .4814). Adjusted mortality did not differ significantly for either donation after circulatory death without normothermic machine perfusion (adjusted hazard ratio, 1.06; 95% confidence interval, 0.80-1.42; P = .6708) or living donor liver transplantation (adjusted hazard ratio, 0.96; 95% confidence interval, 0.69-1.33; P = .8169) compared with donation after circulatory death with normothermic machine perfusion. Donation after circulatory death with normothermic machine perfusion and living donor liver transplantation were not associated with statistically significant differences in adjusted graft failure or mortality, although these findings do not establish equivalence. Living donor liver transplantation was associated with lower unadjusted graft-loss hazards in shorter recipients and selected center-volume subgroups, supporting individualized graft selection.